|
|
|
Kidney Paired Donation Donor Registration |
|
|
|
Fields to be completed by members |
|
|
|
|
|
|
|
Form Section |
Field Label |
Notes |
|
|
|
Add a KPD Donor-Institution |
Home transplant center |
|
|
|
|
Add a KPD Donor |
Is this a non-directed donor? |
|
|
|
|
Add a KPD Donor |
KPD candidate ID |
|
|
|
|
Add a KPD Donor |
Donor name |
|
|
|
|
Add a KPD Donor |
SSN |
|
|
|
|
Add a KPD Donor |
Date of birth |
|
|
|
|
Add a KPD Donor |
Donor status |
|
|
|
|
Add KPD Donor (Non-directed) |
Home transplant center |
|
|
|
|
Add KPD Donor (Non-directed) |
Is this a non-directed donor |
|
|
|
|
Add KPD Donor (Non-directed) |
Donor name |
|
|
|
|
Add KPD Donor (Non-directed) |
SSN |
|
|
|
|
Add KPD Donor (Non-directed) |
Date of birth |
|
|
|
|
Add KPD Donor (Non-directed) |
Donor status |
|
|
|
|
Donor Summary Details-Institution |
Home transplant center |
This field cannot be updated on this page. |
|
|
|
Donor Summary Details-Demographic Information |
Last name |
|
|
|
|
Donor Summary Details-Demographic Information |
First name |
|
|
|
|
Donor Summary Details-Demographic Information |
Middle initial |
|
|
|
|
Donor Summary Details-Demographic Information |
SSN |
|
|
|
|
Donor Summary Details-Demographic Information |
Date of birth |
|
|
|
|
Donor Summary Details-Demographic Information |
Current age |
|
|
|
|
Donor Summary Details-Demographic Information |
Gender |
|
|
|
|
Donor Summary Details-Demographic Information |
Center's patient ID |
|
|
|
|
Donor Summary Details-Demographic Information |
State of permanent residence |
|
|
|
|
Donor Summary Details-Demographic Information |
Permanent zip code |
|
|
|
|
Donor Summary Details-Demographic Information |
Ethnicity/race |
|
|
|
|
Donor Summary Details-Clinical Information |
ABO |
|
|
|
|
Donor Summary Details-Clinical Information |
Height |
|
|
|
|
Donor Summary Details-Clinical Information |
Weight |
|
|
|
|
Donor Summary Details-Clinical Information |
BMI |
|
|
|
|
Donor Summary Details-KPD Information |
Is this a non-directed donor? |
|
|
|
|
Donor Summary Details-KPD Information |
Intended KPD Candidate ID |
|
|
|
|
Donor Summary Details-KPD Information |
Candidate name |
This field is read-only and only displays if the donor is a non-directed donor. |
|
|
|
Donor Summary Details-KPD Information |
Donor's relationship to candidate |
|
|
|
|
Donor Summary Details-KPD Information |
Are you willing to start a chain that continues with a bridge donor? |
|
|
|
|
Donor Summary Details-KPD Information |
Does the donor have health insurance? |
|
|
|
|
Donor Summary Details-KPD Information |
Has the donor signed the Agreement to participate in the KPD Pilot Program? |
|
|
|
|
Donor Summary Details-KPD Information |
Has the donor signed a HIPAA form so that medical information may be shared? |
|
|
|
|
Donor Summary Details-KPD Information |
Has the donor signed a living donor consent form as outlined in the KPD Operational Guidelines? |
|
|
|
|
Donor Summary Details-KPD Information |
Has the donor undergone an evaluation as outlined in the KPD Operational Guidelines? |
|
|
|
|
Donor Summary Details-KPD Information |
Has the donor had all age appropriate cancer screenings as defined by the American Cancer Society? |
|
|
|
|
Donor Summary Details-KPD Information |
KPD status |
|
|
|
|
Donor Summary Details-KPD Information |
Inactive reason |
|
|
|
|
Donor Summary Details-KPD Information |
Other, specify |
|
|
|
|
Donor Summary Details-KPD Information |
Specify |
|
|
|
|
Donor Summary Details-KPD Information |
Removal reason |
|
|
|
|
Donor Summary Details-Comments |
Comments |
|
|
|
|
Medical and Social History |
Home transplant center |
This field cannot be updated on this page. |
|
|
|
Medical and Social History |
History of diabetes |
|
|
|
|
Medical and Social History |
History of cancer |
|
|
|
|
Medical and Social History |
Specify |
|
|
|
|
Medical and Social History |
History of hypertension |
|
|
|
|
Medical and Social History |
Compliant with treatment |
|
|
|
|
Medical and Social History |
Number of medications for hypertension that the donor is on |
|
|
|
|
Medical and Social History |
Please indicate the type of anti-hypertension medication and dosage |
|
|
|
|
Medical and Social History |
Please indicate how long the donor has been on medication for hypertension |
|
|
|
|
Medical and Social History |
History of coronary artery disease (CAD) |
|
|
|
|
Medical and Social History |
Previous gastrointestinal disease |
|
|
|
|
Medical and Social History |
Cigarette use (>20 pack years) ever |
|
|
|
|
Medical and Social History |
Cigarette use continued in last 6 months |
|
|
|
|
Medical and Social History |
Heavy alcohol use (2+ drinks/day) |
|
|
|
|
Medical and Social History |
I.V. drug usage |
|
|
|
|
Medical and Social History |
According to the OPTN policy currently in effect, does the donor have risk factors for blood-borne disease transmission? |
|
|
|
|
Medical and Social History |
Abdominal trauma/surgery |
|
|
|
|
Medical and Social History |
Number of arteries |
|
|
|
|
Medical and Social History |
Number of veins |
|
|
|
|
Medical and Social History |
Ureter |
|
|
|
|
Medical and Social History-Comments |
Comments |
|
|
|
|
Vital Signs-Vital Signs |
Home transplant center |
This field cannot be updated on this page. |
|
|
|
Vital Signs-Vital Signs |
Was 24-hour blood pressure monitor used? |
|
|
|
|
Vital Signs-Vital Signs |
Blood pressure systolic (average of 24- hour period) |
If YES is entered for Was 24-hour blood pressure monitor used |
|
|
|
Vital Signs-Vital Signs |
Blood pressure diastolic (average of 24-hour period) |
If YES is entered for Was 24-hour blood pressure monitor used |
|
|
|
Vital Signs-Vital Signs |
Blood pressure date start (start of 24-hour period) |
If YES is entered for Was 24-hour blood pressure monitor used |
|
|
|
Vital Signs-Vital Signs |
Blood pressure systolic 1 |
If NO is entered for the Was a 24-hour blood pressure monitor used question |
|
|
|
Vital Signs-Vital Signs |
Blood pressure diastolic 1 |
If NO is entered for the Was a 24-hour blood pressure monitor used question |
|
|
|
Vital Signs-Vital Signs |
Blood pressure date 1 |
If NO is entered for the Was a 24-hour blood pressure monitor used question |
|
|
|
Vital Signs-Vital Signs |
Blood pressure systolic 2 |
If NO is entered for the Was a 24-hour blood pressure monitor used question |
|
|
|
Vital Signs-Vital Signs |
Blood pressure diastolic 2 |
If NO is entered for the Was a 24-hour blood pressure monitor used question |
|
|
|
Vital Signs-Vital Signs |
Blood pressure date 2 |
If NO is entered for the Was a 24-hour blood pressure monitor used question |
|
|
|
Vital Signs-Vital Signs |
Was a stress test performed? |
If NO is entered for the Was a 24-hour blood pressure monitor used question |
|
|
|
Vital Signs-Comments |
Comments |
|
|
|
|
Labs-Institution |
Home transplant center |
This field cannot be updated on this page |
|
|
|
Labs-Kidney Function |
Date |
|
|
|
|
Labs-Kidney Function |
Creatinine clearance (24 hours urine collection) (mL/min) |
|
|
|
|
Labs-Kidney Function |
Date |
|
|
|
|
Labs-Kidney Function |
GFR (isotopic method) (mL/min/1.73m2) |
|
|
|
|
Labs-Lab Values |
HbA1c (%) |
|
|
|
|
Labs-Lab Values |
Oral glucose tolerance test (OGTT) |
|
|
|
|
Labs-Lab Values |
Method |
|
|
|
|
Labs-Lab Values |
Date |
|
|
|
|
Labs-Lab Values |
Microalbumin |
|
|
|
|
Labs-Lab Values |
Urine protein-to-creatinine ratio |
|
|
|
|
Labs-Lab Values |
24 hour urine protein |
|
|
|
|
Labs-Urinalysis |
Date |
|
|
|
|
Labs-Urinalysis |
Color |
|
|
|
|
Labs-Urinalysis |
Appearance |
|
|
|
|
Labs-Urinalysis |
pH |
|
|
|
|
Labs-Urinalysis |
Specific gravity |
|
|
|
|
Labs-Urinalysis |
Protein |
|
|
|
|
Labs-Urinalysis |
Glucose |
|
|
|
|
Labs-Urinalysis |
Blood |
|
|
|
|
Labs-Urinalysis |
RBC |
|
|
|
|
Labs-Urinalysis |
WBC |
|
|
|
|
Labs-Urinalysis |
Epith (%) |
|
|
|
|
Labs-Urinalysis |
Casts |
|
|
|
|
Labs-Urinalysis |
Bacteria |
|
|
|
|
Labs-Urinalysis |
Leukocyte esterase |
|
|
|
|
Labs-Lab Panel |
Date |
|
|
|
|
Labs-Lab Panel |
Na (mEq/L) |
|
|
|
|
Labs-Lab Panel |
K+ (mmol/L) |
|
|
|
|
Labs-Lab Panel |
Cl (mmol/L) |
|
|
|
|
Labs-Lab Panel |
CO2 (mmol/L) |
|
|
|
|
Labs-Lab Panel |
BUN (mg/dL) |
|
|
|
|
Labs-Lab Panel |
Creatinine (mg/dL) |
|
|
|
|
Labs-Lab Panel |
Glucose (mg/dL) |
|
|
|
|
Labs-Lab Panel |
Total bilirubin (mg/dL) |
|
|
|
|
Labs-Lab Panel |
Direct bilirubin (mg/dL) |
|
|
|
|
Labs-Lab Panel |
Indirect bilirubin (mg/dL) |
|
|
|
|
Labs-Lab Panel |
SGOT AST (u/L) |
|
|
|
|
Labs-Lab Panel |
SGPT ALT (u/L) |
|
|
|
|
Labs-Lab Panel |
Alkaline phosphatase (u/L) |
|
|
|
|
Labs-Lab Panel |
GGT (u/L) |
|
|
|
|
Labs-Lab Panel |
LDH (u/L) |
|
|
|
|
Labs-Lab Panel |
Albumin (g/dL) |
|
|
|
|
Labs-Lab Panel |
Total protein (g/dL) |
|
|
|
|
Labs-Lab Panel |
Prothrombin (PT) (seconds) |
|
|
|
|
Labs-Lab Panel |
INR |
|
|
|
|
Labs-Lab Panel |
PTT (seconds) |
|
|
|
|
Labs-Lab Panel |
Serum amylase (u/L) |
|
|
|
|
Labs-Lab Panel |
Serum lipase (u/L) |
|
|
|
|
Labs-Complete Blood Count (CBC) |
Date |
|
|
|
|
Labs-Complete Blood Count (CBC) |
WBC (thous/mcL) |
|
|
|
|
Labs-Complete Blood Count (CBC) |
RBC (mill/mcL) |
|
|
|
|
Labs-Complete Blood Count (CBC) |
HgB (g/dL) |
|
|
|
|
Labs-Complete Blood Count (CBC) |
Hct (%) |
|
|
|
|
Labs-Complete Blood Count (CBC) |
Plt (thous/mcL) |
|
|
|
|
Labs-Complete Blood Count (CBC) |
Bands (%) |
|
|
|
|
Labs-Comments |
Comments |
|
|
|
|
Serologies |
Anti-CMV |
|
|
|
|
Serologies |
EBV (VCA) (IgG) |
|
|
|
|
Serologies |
HBsAg |
|
|
|
|
Serologies |
Anti-HBcAb |
|
|
|
|
Serologies |
HBsAb |
|
|
|
|
Serologies |
Anti-HCV |
|
|
|
|
Serologies |
Anti-HIV I/II |
|
|
|
|
Serologies |
Anti-HTLV I/II |
|
|
|
|
Serologies |
RPR/VDRL |
|
|
|
|
Serologies |
EBNA |
|
|
|
|
Serologies |
EBV (VCA) (IgM) |
|
|
|
|
Serologies-Comments |
Comments |
|
|
|
|
Tests and Attachments |
Please select test or attachment |
|
|
|
|
Tests and Attachments-Add New Tests or Attachments |
Test type |
|
|
|
|
Tests and Attachments-Add New Tests or Attachments |
Diagnostic evaluation/comments |
|
|
|
|
Tests and Attachments-Add New Tests or Attachments |
Attach medical image |
|
|
|
|
Tests and Attachments-Add New Tests or Attachments |
Description |
|
|
|
|
Tests and Attachments-Add New Tests or Attachments |
Select file |
All fields in the Tests and Diagnoses table are read-only |
|
|
|
Tests and Attachments-Add New Tests or Attachments (Attachments) |
Please select test or attachment |
|
|
|
|
Tests and Attachments-Add New Tests or Attachments (Attachments) |
Description |
|
|
|
|
Tests and Attachments-Add New Tests or Attachments (Attachments) |
Select File |
All fields in the Attachments table are read-only |
|
|
|
Tests and Attachments-Delete Attachments |
Reason deleted |
|
|
|
|
HLA-Institution |
Home transplant center |
This field cannot be updated on this page |
|
|
|
HLA-HLA Class I |
A |
|
|
|
|
HLA-HLA Class I |
A |
|
|
|
|
HLA-HLA Class I |
B |
|
|
|
|
HLA-HLA Class I |
B |
|
|
|
|
HLA-HLA Class I |
BW4 |
|
|
|
|
HLA-HLA Class I |
BW6 |
|
|
|
|
HLA-HLA Class I |
C |
|
|
|
|
HLA-HLA Class I |
C |
|
|
|
|
HLA-HLA Class II |
DR |
|
|
|
|
HLA-HLA Class II |
DR |
|
|
|
|
HLA-HLA Class II |
DR51 |
|
|
|
|
HLA-HLA Class II |
DR51 |
|
|
|
|
HLA-HLA Class II |
DR52 |
|
|
|
|
HLA-HLA Class II |
DR52 |
|
|
|
|
HLA-HLA Class II |
DR53 |
|
|
|
|
HLA-HLA Class II |
DR53 |
|
|
|
|
HLA-HLA Class II |
DQB1 |
|
|
|
|
HLA-HLA Class II |
DQB1 |
|
|
|
|
HLA-HLA Class II |
DQA1 |
|
|
|
|
HLA-HLA Class II |
DQA1 |
|
|
|
|
HLA-HLA Class II |
DPB1 |
|
|
|
|
HLA-HLA Class II |
DPB1 |
|
|
|
|
HLA-Comments |
Comments |
|
|
|
|
Donor Choices-Institution |
Home transplant center |
This field cannot be updated on this page |
|
|
|
Donor Choices-KPD Donor Choices |
Donor willing to travel? |
|
|
|
|
Donor Choices-KPD Donor Choices |
If Yes, to which center(s) is the donor willing to travel? |
|
|
|
|
Donor Choices-KPD Donor Choices |
Is the donor willing to have his or her kidney shipped? |
|
|
|
|
Donor Choices-KPD Donor Choices |
This donor can ONLY donate his or her following kidney |
|
|
|
|
Donor Choices-KPD Donor Choices |
Pair and center willing to participate in a 3-way match? |
|
|
|
|
Donor Choices-KPD Donor Choices |
Pair and center willing to participate in a chain (not as a bridge donor)? |
|
|
|
|
Donor Choices-KPD Donor Choices |
If matched with an opportunity to be a bridge donor, does the donor consent and the center agree to continue the chain as a bridge donor? |
|
|
|
|
Verify Donor ABO Subtype-Institution |
Home transplant center |
This field cannot be updated on this page |
|
|
|
Verify Donor ABO-Donor Information |
Last name |
This field is read-only |
|
|
|
Verify Donor ABO-Donor Information |
First name |
This field is read-only |
|
|
|
Verify Donor ABO-Donor Information |
Middle initial |
This field is read-only |
|
|
|
Verify Donor ABO-Donor Information |
ABO |
|
|
|
|
Verify Donor ABO-Donor Information |
Age |
This field is read-only |
|
|
|
Verify Donor ABO-Donor Information |
Gender |
This field is read-only |
|
|
|
Verify Donor ABO-Donor Information |
First user ABO entry |
This field is read-only |
|
|
|
Verify Donor ABO Subtype-Institution |
Home transplant center |
This field cannot be updated on this page |
|
|
|
Verify Donor ABO Subtype-Donor Information |
Last name |
This field is read-only |
|
|
|
Verify Donor ABO Subtype-Donor Information |
First name |
This field is read-only |
|
|
|
Verify Donor ABO Subtype-Donor Information |
Middle initial |
This field is read-only |
|
|
|
Verify Donor ABO Subtype-Donor Information |
ABO |
|
|
|
|
Verify Donor ABO Subtype-Donor Information |
Age |
This field is read-only |
|
|
|
Verify Donor ABO Subtype-Donor Information |
Gender |
This field is read-only |
|
|
|
Verify Donor ABO Subtype-Donor Information |
First ABO subtype user |
This field is read-only |
|
|
|
Manage Bridge Donors-Pending Bridge Donors |
Select home transplant center |
|
|
|
|
Manage Bridge Donors-Pending Bridge Donors |
KPD donor ID |
This field is read-only |
|
|
|
Manage Bridge Donors-Pending Bridge Donors |
Donor name |
This field is read-only |
|
|
|
Manage Bridge Donors-Pending Bridge Donors |
Match run date donor became a bridge donor |
This field is read-only |
|
|
|
Manage Bridge Donors-Pending Bridge Donors |
Bridge donor on hold |
This field is optional |
|
|
|
Manage Bridge Donors-Pending Bridge Donors |
Access bridge donor record |
|
|
|
|
Manage Bridge Donors-Pending Bridge Donors |
Exchange number |
This field is read-only |
|
|
|
Manage Bridge Donor Record |
Home transplant center |
|
|
|
|
Manage Bridge Donor Record |
KPD donor ID |
This field is read-only |
|
|
|
Manage Bridge Donor Record |
Donor name |
This field is read-only |
|
|
|
Manage Bridge Donor Record |
Bridge donor status |
|
|
|
|
Manage Bridge Donor Record |
Bridge donor status date |
|
|
|
|
Manage Bridge Donor Record |
Bridge donor on hold |
This field is optional |
|
|
|
Manage Bridge Donor Record |
KPD donor status |
This field is read-only |
|
|
|
Manage Bridge Donor Record |
Match run date donor became a bridge donor |
This field is read-only |
|
|
|
Manage Bridge Donor Record |
Exchange number |
This field is read-only |
|
|
|
Manage Bridge Donor Record-Bridge donor status: Declined to donate reason |
Bridge donor status declined to donate reasons |
|
|
|
|
Manage Bridge Donor Record-Bridge donor status: Declined to donate reason |
Life circumstances have changed |
|
|
|
|
Manage Bridge Donor Record-Bridge donor status: Declined to donate reason |
Medical condition has changed |
|
|
|
|
Manage Bridge Donor Record-Bridge donor status: Declined to donate reason |
Other reasons |
|
|
|
|
Manage Bridge Donor Record-Bridge donor status: Declined to donate reason |
Enter Comments |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PUBLIC BURDEN STATEMENT: |
|
|
|
|
|
The private, non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform the following OPTN functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monitor compliance of member organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0157 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non-profit OPTN also are well protected by a number of the Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed by OMB Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments Automated Information Systems Security Program Handbook. The public reporting burden for this collection of information is estimated to average 0.7 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|